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Brazilian Journal of Anesthesiology... 2015Strabismus surgery is a frequently performed pediatric ocular procedure. A frequently occurring major problem in patients receiving this treatment involves the... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND AND OBJECTIVES
Strabismus surgery is a frequently performed pediatric ocular procedure. A frequently occurring major problem in patients receiving this treatment involves the oculocardiac reflex. This reflex is associated with an increased incidence of postoperative nausea, vomiting, and pain. The aim of this study was to investigate the effects of a sub-Tenon's block on the oculocardiac reflex, pain, and postoperative nausea and vomiting.
METHODS
Forty patients aged 5-16 years with American Society of Anesthesiologists status I-II undergoing elective strabismus surgery were included in this study. Patients included were randomly assigned into two groups by using a sealed envelope method. In group 1 (n=20), patients did not receive sub-Tenon's anesthesia. In group 2 (n=20), following intubation, sub-Tenon's anesthesia was performed with the eye undergoing surgery. Atropine use, pain scores, oculocardiac reflex, and postoperative nausea and vomiting incidences were compared between groups.
RESULTS
There were no significant differences between groups with regard to oculocardiac reflex and atropine use (p>0.05). Pain scores 30min post-surgery were significantly lower in group 2 than in group 1 (p<0.05). Additional analgesic needed during the postoperative period was significantly lower in group 2 compared to group 1 (p<0.05).
CONCLUSIONS
In conclusion, we think that a sub-Tenon's block, combined with general anesthesia, is not effective and reliable in decreasing oculocardiac reflex and postoperative nausea and vomiting. However, this method is safe for reducing postoperative pain and decreasing additional analgesia required in pediatric strabismus surgery.
Topics: Adolescent; Anesthesia, Local; Child; Child, Preschool; Female; Humans; Male; Pain, Postoperative; Postoperative Nausea and Vomiting; Reflex, Oculocardiac; Strabismus
PubMed: 26323732
DOI: 10.1016/j.bjane.2014.02.003 -
Anaesthesia, Critical Care & Pain... Apr 2021
Topics: Anesthesia; Anesthesia, Local; Anesthetics, Local; Humans; Incidence; Lidocaine; Melanoma; Pain, Postoperative; Reflex, Oculocardiac; Uveal Neoplasms
PubMed: 33753295
DOI: 10.1016/j.accpm.2021.100835 -
Anesthesia, Essays and Researches 2021Strabismus surgery may be associated with several undesirable complications as increased incidence of the oculocardiac reflex (OCR), hemodynamic changes, emergency...
BACKGROUND
Strabismus surgery may be associated with several undesirable complications as increased incidence of the oculocardiac reflex (OCR), hemodynamic changes, emergency agitation (EA), postoperative pain, nausea, and vomiting. Previous studies suggested that deeper anesthesia monitored by bispectral index (BIS) protects against OCR. This study aims to evaluate the effect of the type of anesthesia on the quality of anesthesia in pediatric patients.
PATIENTS AND METHODS
One hundred American Society of Anesthesiologists physical status classes I and II pediatric patients, aged between 3 and 6 years old of both genders, who were subjected to strabismus surgery under general anesthesia were enrolled in this study. Patients were randomized into two equal groups (each = 50); in the first group, anesthesia was induced and maintained with sevoflurane (Group S), and in the second group, anesthesia was induced and maintained with propofol (Group P). Hemodynamics and BIS were monitored, and OCR and the need for atropine were recorded. Furthermore, EA using the Cravero scale was recorded.
RESULTS
The propofol group showed a higher incidence of OCR while the sevoflurane group had a higher incidence of postoperative agitation, pain, nausea, and vomiting, without statistically significant differences regarding hemodynamics.
CONCLUSION
Although sevoflurane anesthesia may be superior to propofol in ameliorating OCR, it has been associated with an increased incidence of postoperative complications.
PubMed: 35320953
DOI: 10.4103/aer.AER_93_20 -
World Neurosurgery Feb 2019The trigeminocardiac reflex is a sudden onset of bradycardia, hypotension, apnea, or gastric hypermotility in response to stimulation of the trigeminal nerve. (Review)
Review
BACKGROUND
The trigeminocardiac reflex is a sudden onset of bradycardia, hypotension, apnea, or gastric hypermotility in response to stimulation of the trigeminal nerve.
CASE DESCRIPTION
A 60-year-old female underwent a left orbitozygomatic craniotomy to debulk a large skull base epidermoid cyst compressing the brainstem and cranial nerves. Intraoperatively, retraction of the temporalis muscle consistently produced asystole. Cessation of retraction resulted in prompt return of sinus rhythm.
CONCLUSIONS
Our report describes an unusual and extreme example of the trigeminocardiac reflex and explores possible etiologies. This is the third reported surgical case in which manipulation of the temporalis muscle alone was sufficient to elicit bradycardia and asystole, and the first such case within the context of neurosurgery. We emphasize the importance of surgical teams to be cognizant of such extreme examples of this reflex.
Topics: Bone Diseases; Epidermal Cyst; Female; Heart Arrest; Humans; Intraoperative Complications; Middle Aged; Reflex, Trigeminocardiac; Skull Base; Temporal Muscle
PubMed: 30399470
DOI: 10.1016/j.wneu.2018.10.186 -
Anaesthesia and Intensive Care Jul 2020Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4% lifetime risk of developing strabismus. Current treatment...
Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4% lifetime risk of developing strabismus. Current treatment options include pharmacological injection of botulinum toxin or bupivacaine, conventional corrective surgery, adjustable suture surgery and minimally invasive surgery. Repeated surgery is common as each operation has a 60%-80% chance of successful correction. The benefits of early surgical correction in large-angle strabismus in children outweigh the risks of anaesthesia. General anaesthesia is suitable for patients of all age groups, for complicated or repeated surgery, and bilateral eye procedures. Regional ophthalmic block reduces the incidence of oculocardiac reflex and emergence agitation, and provides postoperative analgesia, but requires a cooperative patient as many experience discomfort. Topical anaesthesia has been used in pharmacological injection, minimally invasive surgery, uncomplicated conventional strabismus surgery and some adjustable suture strabismus surgery. Its use, however, is only limited to cooperative adult patients. Prophylactic antiemesis with both ondansetron and dexamethasone is recommended, especially for children. A multimodal analgesia approach, including paracetamol, intravenous non-steroidal anti-inflammatory drugs, topical local anaesthetic and minimal opioid usage, is recommended for postoperative analgesia, while a supplementary regional ophthalmic block is at the discretion of the team.
Topics: Adult; Anesthesia, Local; Anesthetics; Bupivacaine; Child; Humans; Ophthalmologic Surgical Procedures; Strabismus
PubMed: 32777929
DOI: 10.1177/0310057X20937710 -
Archives of Plastic Surgery Sep 2017Among the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed...
BACKGROUND
Among the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration.
METHODS
The medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries.
RESULTS
All patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1-108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13-36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur.
CONCLUSIONS
Patients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.
PubMed: 28946722
DOI: 10.5999/aps.2017.44.5.407 -
Revista Espanola de Anestesiologia Y... May 2015To analyze the effectiveness and usefulness of contact topical anesthesia in strabismus surgery in adult patients.
OBJECTIVE
To analyze the effectiveness and usefulness of contact topical anesthesia in strabismus surgery in adult patients.
MATERIAL AND METHODS
A prospective study was conducted on 20 patients undergoing strabismus surgery using contact topical anesthesia and sedation with remifentanil. The intensity of pain was recorded using a numeric pain rating scale at the time of anesthesia implementation, during the surgical procedure, 30 min afterwards, and during the first postoperative day. The incidence of oculocardiac reflex, postoperative nausea and vomiting, corneal ulcers, patient satisfaction (numerically from 0 to 10) and the degree of residual ocular deviation were also assessed.
RESULTS
The operation was performed successfully in all patients. Average pain intensity was 1.40 ± 1.73 during anesthesia implementation, 4.20 ± 2.57 during the surgical procedure, 2.50 ± 2.54 30 min after surgery, and 3.55 ± 2.89 during the first postoperative day. Oculocardiac reflex was observed in 7 patients (35%), postoperative nausea and vomiting in 4 (20%), and corneal ulcer in 4 (20%). The patient satisfaction was 9.53 ± 2.51. More than two-thirds (70%) of patients had a residual ocular deviation less than 10 prism diopters.
CONCLUSIONS
Contact topical anesthesia is a safe and effective alternative for strabismus surgery in adult patients. Contact topical anesthesia provides adequate pain control, lower incidence of postoperative nausea and vomiting and oculocardiac reflex, and optimal setting of ocular alignment.
Topics: Administration, Ophthalmic; Adult; Aged; Aged, 80 and over; Anesthesia, Local; Anesthetics, Local; Bupivacaine; Conscious Sedation; Corneal Ulcer; Female; Humans; Hypnotics and Sedatives; Lidocaine; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Reflex, Oculocardiac; Remifentanil; Strabismus; Treatment Outcome; Young Adult
PubMed: 25217143
DOI: 10.1016/j.redar.2014.07.005 -
Saudi Journal of Anaesthesia 2017Emergence agitation, vomiting, and oculocardiac reflex (OCR) in children undergoing strabismus surgery under general anesthesia are common problems. The purpose of this...
BACKGROUND
Emergence agitation, vomiting, and oculocardiac reflex (OCR) in children undergoing strabismus surgery under general anesthesia are common problems. The purpose of this study was to determine whether the effect of analgesia can reduce the incidence of these problems. We compared the effects of sub-Tenon's injection versus intravenous (IV) and rectal paracetamol in this surgery.
METHODS
In a prospective, randomized, double-blind study, ninety patients ranging in age from 4 to 8 years scheduled for extraocular muscle surgery for strabismus were included in this study. After induction of anesthesia, just before the surgery, children were divided into three groups ( = 30 for each group) Group A received sub-Tenon's anesthesia with 2.5% bupivacaine (0.08 ml/kg). Group B received IV paracetamol (20 mg/kg). Group C received paracetamol rectal suppository (40 mg/kg). The occurrence of oculocardiac reflex (OCR) intraoperatively was recorded. Then, in the Postanesthesia Care Unit, patients were assessed for their emergence behaviors. Vomiting was also noticed.
RESULTS
The OCR developed in few patients, and there was no significant difference between the groups. The highest number of patients with agitation was in Group C followed by Group B then Group A. Vomiting was significantly low in Group A followed by Group B then Group C.
CONCLUSION
Sub-Tenon block in strabismus surgery in children decreased the incidence of postoperative agitation and vomiting compared with IV paracetamol then rectal paracetamol. There was no difference between sub-Tenon block and paracetamol in the incidence of oculocardiac reflex.
PubMed: 28217058
DOI: 10.4103/1658-354X.197349 -
Paediatric Anaesthesia Dec 2017Postoperative nausea and postoperative vomiting are frequent but often missed complications after general anesthesia in pediatric patients. Because inhaled anesthetics... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Postoperative nausea and postoperative vomiting are frequent but often missed complications after general anesthesia in pediatric patients. Because inhaled anesthetics are known to trigger postoperative vomiting, total intravenous anesthesia is often administered in high-risk children to avoid the use of inhalational anesthesia. Since inhalational anesthesia might be advantageous in some situations, the question is raised whether administration of pharmacological prophylaxis offers equal protection from postoperative vomiting compared with total intravenous anesthesia alone.
AIM
The aim of this systematic review was to compare total intravenous anesthesia with single-drug pharmacological prophylaxis for the protection of postoperative vomiting in pediatric patients.
METHODS
We conducted a systematic review (EMBASE, MEDLINE, and CENTRAL) with meta-analysis on randomized controlled trials including patients <18 years of age undergoing general anesthesia, with one group receiving propofol-based total intravenous anesthesia and another group receiving inhalational anesthesia with single pharmacological prophylaxis. Primary outcome was the overall incidence for postoperative vomiting. Secondary outcomes included early and late postoperative vomiting, the need for postoperative antiemetic medication, time to first oral intake, duration of stay in the postanesthesia care unit, and any adverse events defined as such by the respective authors. Risk ratios (RR) or mean differences (MD) with 95% confidence intervals (95% CI) were calculated using a random effects model with inverse variance weighting.
RESULTS
Four randomized controlled trials including 558 children were included in the final analysis. All patients underwent strabismus surgery. Total intravenous anesthesia and single pharmacological prophylaxis were equally effective in preventing overall postoperative vomiting (RR 0.99 [95% CI 0.77; 1.27]; 4 trials), as well as vomiting in the early (1.48 [0.78; 2.83]; 4 trials) and late (0.89 [0.56;1.42]; 2 trials) postoperative period. There was no difference in the need for postoperative antiemetic medication. Although patients resumed drinking and eating significantly earlier following total intravenous anesthesia (MD -1.40 hours [-2.01; -0.80], P < .001), the duration of PACU stay did not differ between groups. The incidence of intraoperative oculocardiac reflex was the only reported adverse event, which was more likely to occur after total intravenous anesthesia (1.86 [1.01; 3.41]).
CONCLUSION
Single pharmacological prophylaxis appears equally effective compared with total intravenous anesthesia in preventing postoperative vomiting in pediatric patients. However, during strabismus surgery, total intravenous anesthesia increases the risk for bradycardia due to oculocardiac reflex. Thus, when anesthesia is maintained with inhalational anesthetics, its emetogenic effects can sufficiently be compensated by the addition of a single prophylactic antiemetic medication.
Topics: Adolescent; Anesthesia, Intravenous; Antiemetics; Child; Child, Preschool; Humans; Infant; Infant, Newborn; Postoperative Nausea and Vomiting; Randomized Controlled Trials as Topic
PubMed: 29094418
DOI: 10.1111/pan.13268 -
World Neurosurgery Dec 2014The oculocardiac reflex (OCR) is a sudden decrease in heart rate resulting from mechanical manipulation of the orbit, especially due to traction on the orbital contents....
OBJECTIVE
The oculocardiac reflex (OCR) is a sudden decrease in heart rate resulting from mechanical manipulation of the orbit, especially due to traction on the orbital contents. The purpose of this study was to determine the incidence and clinical ramifications of OCR elicitation by the orbitozygomatic (OZ) approach.
METHODS
Electrocardiographic strips were collected prospectively from 104 patients undergoing OZ approaches. Recording was started at the commencement of the craniotomy cuts and was stopped after completion of the OZ osteotomy. Each recording was divided into stage 1, which encompassed the time between the start of the craniotomy cuts to the commencement of the osteotomy cuts, and stage 2, which encompassed the time from commencement of osteotomy cuts until completion of all bone work and dural tacking Orbital manipulation occurred exclusively during stage 2. A decrease in heart rate of 10 bpm or more between stage 1 and stage 2 was recorded as an OCR event.
RESULTS
In our 104 patients we detected OCR events 31.7% of the time. There was no significant difference in rate of OCR occurrence found in analysis of the covariates of hypertension, hyperlidemia, diabetes mellitus, hypothyroidism/hyperthyroidism, β-blocker use, calcium channel blocker use, or tobacco use. In each case, transient cessation of orbital manipulation was sufficient to normalize heart rate. No patients required anticholinergic intervention as a result of OCR, and there were no postoperative ramifications of the OCR.
CONCLUSIONS
OCR occurs in nearly one-third of patients who undergo the OZ approach. However, simple cessation of orbital manipulation is sufficient to normalize the patient's heart rate. Rarely is medical management required or does there appear to be any significant postoperative ramifications.
Topics: Adult; Aged; Cohort Studies; Craniotomy; Female; Heart Rate; Humans; Incidence; Male; Middle Aged; Neurosurgical Procedures; Orbit; Prospective Studies; Reflex, Oculocardiac; Young Adult; Zygoma
PubMed: 24001795
DOI: 10.1016/j.wneu.2013.08.032